Assessment of the Heart, Great vessels

of the neck, and Peripheral Vascular

system

Great vessels of the neck

Jugular veins
Carotid arteries

JUGULAR VENOUS DISTENTION

JVD

Assessment
Position

client supine
Then head elevated at 45 degrees
INSPECTION:
Lifts,

heaves
PMI (assess location)

Inspection
Chest

for visible cardiac motion

Estimate Jugular venous pressure
Patient supine and head elevated to
15-30 degrees.
JVP is the distance b/w highest point
at which pulsation can be seen and
the sternal angle

Jugular venous pressure

An indirect measure of right atrial pressure.
Measured in centimeters from the sternal angle

and is best visualized with the patient's head

rotated to the left.
Described for its quality and character, effects

of respiration, and patient position-induced

changes.

Palpation

Physical Landmarks

Suprasternal
notch
Sternum
Manubriosternal
angle Angle of
Louis
Intercostals
Spaces

palpations
Palpate

for PMI; easiest if patient sits

up and leans forward
has a diameter of 2cm and located
with 10 cm of the midsternal line
Palpate for general cardiac motion with
fingertips and patient in supine position
Palpate for radial, carotid, brachial,
femoral, popliteal, posterior tibial And
dorsalis pedis peripheral pulses

palpations
See

figure 4-12
Rate strength of the pulse normal,
diminished, or absent on a scale of 0
to +4, where 2+ is normal. See table
4-6

Auscultation:
Auscultatory Sites

Auscultation
With a stethoscope
Use diaphragm to assess higher
pitched sounds
Needs a lot of practice and experience
Listen in a quiet area or to close eyes
to reduce conflicting stimuli
See also figure 4-10 for auscultatory
Sites

Auscultatory Sites: Cont.

Auscultatory Sites
The auscultatory Sites are close to but not the

same as the anatomic locations of the valves.

Aortic area2nd ICS at the right sternal border
Pulmonic 2nd ICS at the left sternal border
Tricuspid lt lower sternal border
Mitral cardiac apex

Heart Sounds
Heart sounds are characterized by location,

pitch, intensity, duration, and timing within the

cardiac cycle

Heart Sounds
High-pitched sounds such as S 1 and S2,

murmurs of aortic and mitral regurgitation, and

pericardial friction rubs are best heard with the
diaphragm.
The bell is preferred for low-pitched sounds

such as S3 and S4.

Heart Sounds S1(Lub)

S1: Closure of AV valves

(mitral and tricuspid
valves: M1 before T1)
Correlates with the
carotid pulse
Loudest at the cardiac
apex
Can be split but not
often

Heart Sounds S2(Dub)

S2: Closure of
Semilunar valves (aortic
& pulmonic)
Loudest at the base of
the heart
May have a split sound
(A2 before P2)

Heart Sounds S2(Dub)

S1

and S2 assessed in all four sites in upright

and supine position
S1 precedes and the S2 follows the carotid
pulse

Heart Sounds Cont.

Base (R/L 2nd ICS)

S2 louder than S1

Apex
S1 louder than S2

Normal physiologic S2 Split

Best heard at pulmonic area
during inspiration

Fixed split (no variation

with inspiration)

Extra Heart Sounds

S3

Due to volume overload

Due to Rapid ventricular
filling: ventricular gallop
S1 -- S2-S3 (Ken--tuc-ky)

S4

Due to pressure overload

Due to slow ventricular
contraction: atrial gallop
S4-S1 S2 (Ten-nessee)

Extra Heart Sounds

S3

low-pitched sound
usually heard at the apex of
the heart.
caused by rapid filling and
stretching of the left
ventricle when the left
ventricle is somewhat
noncompliant.
characteristic of volume
overloading, such as in CHF
(especially left-sided heart
failure), tricuspid or mitral
valve insufficiency.

S4

a dull, low-pitched postsystolic

atrial gallop
usually caused by reduced
ventricular compliance.
best heard at the apex in the
left lateral position.
occurs with reduced ventricular
compliance and is present in
conditions such as aortic
stenosis, hypertension,
hypertrophic cardiomyopathies,
and coronary artery disease.
less specific for CHF than S3.

Murmurs

Turbulent blood flow across a valve or a disease such

as anemia or hyperthyroidism

Listen for murmurs in the same auscultatory sites

APETM

Systolic b/w S1 & S2

Diastolic b/w S2 & S1

Characteristics of Heart Sounds

Type of
Murmur

Midsystolic

Pansystolic

Diastolic

Examples

Location

Pitch

Radiation

Aortic
stenosis

2nd RICS

Medium

Neck, left
sternal border Harsh

Pulmonic
stenosis

2nd and 3rd

LICS

Medium

Left shoulder Harsh

and neck

Hypertrophic 3rd and 4th

cardiomyopat LICS
hy

Medium

Left sternal
border to
apex

Harsh

Mitral
regurgitation

Apex

Medium to
high

Left axilla

Blowing

Tricuspid
regurgitation

Lower left
sternal border Medium

Right
sternum,
xiphoid

Blowing

Ventricular
septal defect

3rd, 4th, and High

5th LICS

Aortic
regurgitation

2nd to 4th
LICS

Mitral stenosis Apex

Quality

Often harsh

High

Apex

Low

Little or none

Blowing

Murmurs

They are classified by

timing and duration within the cardiac cycle (systolic,
diastolic, and continuous),
location,
intensity,
shape (configuration or pattern),
pitch (frequency),
quality, and radiation

Murmurs

Grade I :barely audible

Gr II : audible but quiet and soft
Gr III : moderated loud, without thrust or thrill
Gr IV : loud, with thrill
Gr V : louder with thrill, steth on chest wall
Gr VI : loud enough to be heard before steth on chest

Murmurs

Thrill:
a palpable murmur

Bruits:

Vascular murmur
sounds made by turbulent blood flow
Heard over blood vessels with constricted lumens.
Carotid and femoral are routinely assessed for bruits
Sometimes found over the vertebral, subclavian and abdominal arteries